Samsam Ateye: Prevention of Future Deaths Report

Hospital Death (Clinical Procedures and medical management) related deaths

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Date of report: 03/09/2024  

Ref: 2024-0662 

Deceased name: Samsam Ateye 

Coroners name: Anton Van Dellen 

Coroners Area: West London 

Category: Hospital Death (Clinical Procedures and medical management) related deaths 

This report is being sent to: NHS England 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: 

1. NHS England
1CORONER

I am Dr Anton van Dellen, HM Assistant Coroner, for the coroner area of West London 
2CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  
3INVESTIGATION and INQUEST

An investigation was commenced into the death of Samsam Haji Ali Ateye, aged 68. The investigation concluded on 30 August 2024. The conclusion in the inquest was: 
Complications following surgical procedure.

The medical cause of death was
1a Multiorgan failure 
1b Following bio prosthetic aortic valve replacement surgery 
1c Aortic stenosis with ventricular hypertrophy and fibrosis 
II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia 
4CIRCUMSTANCES OF THE DEATH

Samsam died on 12 May 2023 at Harefield Hospital, Uxbridge. She had been diagnosed  with severe aortic stenosis which was symptomatic. A Multi-Disciplinary Team (MDT)  meeting decided that she would benefit from aortic valve replacement surgery. She had an out-patient pre-operative Covid-19 Polymerase Chain Reaction (PCR) test performed  on 18 April 2023, which was negative.  She was admitted to hospital on the day of her  surgery on 20 April 2023.  On admission, she had another Covid-19 PCR test performed on her that morning, before her surgery.  She had aortic valve replacement surgery that  afternoon. Post-operatively, the surgeons who operated on her became aware, that  evening, that the Covid-19 PCR test performed on her on the morning of surgery was  positive.  A subsequent three further Covid-19 tests performed in hospital after 20 April  2023 were also positive.  Post-operatively, she developed episodes of atrial fibrillation, as  well as sepsis which was probably bacterial and was of unknown origin. She died due to  sepsis which caused Multi-Organ Failure. The inquest heard evidence that the consultant surgeon was very worried upon learning that Samsam was Covid positive as patients who are Covid positive who undergo cardiac surgery have a real risk of excessive  complications and mortality. The inquest heard that policy about pre-operative testing for  Covid for cardiothoracic surgery and the form of that testing was formulated at a national level by NHS England. 
5CORONER’S CONCERNS

During the inquest, the evidence revealed matters giving rise to concern. In my opinion  there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows. –

1. The policy for testing for Covid-19 before cardiac surgery, specifically valve replacement surgery.
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th October 2024.  
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 

1. [REDACTED]
2. [REDACTED]
3. [REDACTED]
4. [REDACTED]
5. [REDACTED]
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20. [REDACTED]
21. [REDACTED]
22. [REDACTED]
23. Guys and St Thomas’ NHS Foundation Trust

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. 
I may also send a copy of your response to any other person who I believe may find it useful or of interest. 
The Chief Coroner may publish either or both in a complete or redacted or summary  form. He may send a copy of this report to any person who he believes may find it useful or of interest. 
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 
93rd September 2024 

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